TOWN OF ARGYLE APPLICATION FOR ON-SITE SEWAGE FACILITY NEW CONSTRUCTION TCEQ REGION NUMBER COUNTY OF INSTALLATION. (Last) (First) (Middle)

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1 TOWN OF ARGYLE APPLICATION FOR ON-SITE SEWAGE FACILITY NEW CONSTRUCTION TCEQ REGION NUMBER OFFICE USE ONLY APPLICATION NO. DATE RECEIVED AMOUNT COUNTY OF INSTALLATION 1. PROPERTY OWNERS NAME: 2. CURRENT MAILING ADDRESS: (Last) (First) (Middle) 3. HOME PHONE NO.: ( ) OTHER or FAX NO.: ( ) SITE ADDRESS: 5. PROPERTY LEGAL DESCRIPTION: Acreage: Plat Date: Subdivision name (if applicable): PLEASE ATTACH VERIFICATION OF LEGAL DESCRIPTION SUCH AS A COPY OF: DEED, PLAT MAP, SURVEY, OR OTHER DOCUMENTATION CONTAINING LEGAL DESCRIPTION 6. DIRECTIONS TO SITE: 7. SOURCE OF WATER: Private Well Public Water Supply (Name of Supplier) 8. SINGLE FAMILY RESIDENCE: No. of Bedrooms: Living Area (ft 2 ): 9. COMMERCIAL/INSTITUTIONAL (other than single-family residence) TYPE: BUSINESS / INSTITUTION NAME: RESPONSIBLE OFFICIAL: 10. SITE EVALUATOR: LICENSE NO. PHONE NO.: ( ) OTHER or FAX NO.: ( ) NO. OF EMPLOYEES/UNITS: MAILING ADDRESS: CITY: STATE: ZIP: 11. INSTALLER: LICENSE NO.: PHONE NO.: ( ) OTHER or FAX NO.: ( ) _ MAILING ADDRESS: CITY: STATE: ZIP: I certify that the above statements are true and correct to the best of my knowledge. Authorization is hereby given to the Town of Argyle to enter upon the above described property for the purpose of soil/site evaluation and investigation of an on-site sewage facility. SIGNATURE OF OWNER: DATE: This application may be executed in separate and multiple counterparts, which together shall constitute a single instrument. Any executed signature on this agreement may be transmitted by digital or electronic transmission, including but not limited to facsimile transmission and electronic mail. Any signature affixed to this application shall constitute an original signature for all purposes. TOA-0001 (rev 11/12/2014) Page 1 of 2

2 TOWN OF ARGYLE ON-SITE SEWAGE FACILITY TECHNICAL INFORMATION FOR PERMIT PROFESSIONAL DESIGN REQUIRED?: Yes No If yes, professional design attached: Yes No Designer Name: License Type and No. _ Phone No. ( ) Other or Fax No. ( ) Mailing Address: City: State: Zip: I. TYPE AND SIZE OF PIPING FROM: (EXAMPLE: 4" SCH 40 PVC) Stub out to treatment tank: Treatment tank to disposal system: II. DAILY WASTEWATER USAGE RATE: Q= (gallons/day) Water Saving Devices: Yes No III. TREATMENT UNIT(S): Septic Tank Aerobic Unit A. Tank Dimensions: Liquid Depth (bottom of tank to outlet): Size Proposed: (gal) Manufacturer : Material/Model #: Pretreatment Tank : Yes SIZE : (gal) No NA Pump/Lift Tank : Yes SIZE : (gal) No NA B. OTHER Yes No If yes, please attach description. IV. DISPOSAL SYSTEM: Disposal Type: Manufacturer and Model: Area Proposed : square feet V. ADDITIONAL INFORMATION: NOTE - THIS INFORMATION MUST BE ATTACHED FOR REVIEW TO BE COMPLETED. A. Soil/Site evaluation B. Planning materials (If Applicable) DO NOT BEGIN CONSTRUCTION PRIOR TO OBTAINING AUTHORIZATION TO CONSTRUCT. UNAUTHORIZED CONSTRUCTION CAN RESULT IN CIVIL AND/OR ADMINISTRATIVE PENALTIES. SIGNATURE OF INSTALLER OR DESIGNER: DATE: If you have questions on how to fill out this form or about the on-site sewage facility program, please contact us at Argyle Town Hall or at Individuals are entitled to request and review their personal information that the agency gathers on its forms. They may also have any errors in their information corrected. To review such information, contact us at This application may be executed in separate and multiple counterparts, which together shall constitute a single instrument. Any executed signature on this agreement may be transmitted by digital or electronic transmission, including but not limited to facsimile transmission and electronic mail. Any signature affixed to this application shall constitute an original signature for all purposes. TOA-0001 (rev 11/12/2014) Page 2 of 2

3 COUNTY OF DENTON STATE OF TEXAS AFFIDAVIT According to Texas Commission on Environmental Quality Rules for On-Site Sewage (OSSFs) Facilities, this document is filed in the Deed Records of Denton County, Texas. I The Texas Health and Safety Code, Chapter 366 authorizes the Texas Commission on Environmental Quality (commission) to regulate on-site sewage facilities (OSSFs). Additionally, the Texas Water Code (TWC), and 5.013, gives the commission primary responsibility for implementing the laws of the State of Texas relating to water and adopting rules necessary to carry out its powers an duties under the TWC. The commission, under the authority of the TWC and the Texas Health and Safety Code, requires owner s to provide notice to the public that certain types of OSSFs are located on specific pieces of property. To achieve this notice, the commission requires a recorded affidavit. Additionally, the owner must provide proof of the recording to the OSSF permitting authority. This recorded affidavit is not a representation or warranty by the commission of the suitability of this OSSF, nor does it constitute any guarantee by the commission that the appropriate OSSF was installed. II An OSSF requiring a maintenance contract, according to 30 Texas Administrative Code (12) will be installed on the property described as Legal description: Property Address: The property is owned by: This OSSF must be covered by a continuous maintenance contract. All maintenance on this OSSF shall be performed by an approved maintenance company, and a signed maintenance contract must be submitted to the Town of Argyle within 30 days after the property has been transferred. Upon any sale or transfer of the above-described property, the permit for the OSSF shall be transferred to the buyer or new owner. A copy of the planning materials for the OSSF may be obtained from the Town of Argyle. WITNESS BY HAND(S) ON THIS DAY OF,. Owner(s) signature(s) SWORN TO AND SUBSCRIBED BEFORE ME ON THIS DAY OF,. (SEAL) Notary Public, State of Texas My Commission Expires: Notary s Printed Name

4 OSSF Certification for Accessory Building Distances Property Owner: has submitted an application for an Accessory Building Permit from the Town of Argyle to be located at: Owner acknowledges compliance of Separation Distances for On-Site Sewage Facilities as prescribed by the Texas Commission on Environmental Quality, 30TEC (10) As listed below. Separation Distances for On-Site Sewage Facilities From: Distances in Feet: Tanks 5' Soil Absorption Systems 5' & Unlined ET beds Lined Evapotranspiration Beds 5' Sewer pipe with watertight joints 5' Surface Application (Edge of Spray Area) Drip Irrigation Outside of spray area May not be placed under foundations I hereby certify that I will comply with all provisions of laws and ordinances governing On- Site Sewage Facility separation distances whether specified above or not. The granting of a permit does not presume to give authority to violate or cancel the provisions of any other State, Federal, or local law regulating On-Site Sewage Facility separation distances. Signature of Owner Date

5 On Site Sewage Facility Permit Application Check List Address: Date: Valuation: ***All items listed below are required for an OSSF application review*** OSSF Permit Application completely filled out with original signature. Site Evaluation The soil must be evaluated and classified by a TCEQ Licensed Site Evaluator or Professional Engineer. Soil Analysis drill two (2) soil borings or excavate two (2) backhoe pits at opposite ends of the proposed disposal area to determine the characteristics of the soil. OSSF Technical Information Sheet completely filled out. Site Diagram Original and to scale where applicable in accordance with Texas Administrative Code Title 30 Chapter 285. (Drawing shall include all existing and future structures, pools, sprinkler/disposal area, elevations, slopes, property lines, landscaping, trees, ditches, drainage easements, creeks, ponds, water wells and shall indicate if the location or a portion of the property is in the 100 year floodplain and the drawing shall also indicate if the 100 year floodplain does not exist within the tract. System Manufacturer and Design Systems of 5,000 gallons or more, Must be submitted to the Texas Commission on Environmental Quality (TCEQ) for review. Spray Irrigation Design. Pump/Alarm Diagram. Affidavit Surface Irrigation to be completed by the owner of the property and must be notarized and filed with Denton County Records (include the receipt for affidavit with the permit application). Upon sale or legal transfer of the above described property, the permit for the OSSF shall be transferred to the buyer or new owner. Aerobic System Maintenance Contract by an approved TCEQ Maintenance Provider to be submitted at the time of application in order to construct the OSSF. An updated initial contract is also to be submitted to reflect the date of sale by the builder for a new single family dwelling or date of notice of approval for an existing single family dwelling with new ownership information. Copies of TCEQ OSSF Installer License and Maintenance Provider License.